By Catherine Lightfoot, CPA, CHBC, Director of Healthcare at EEPB
We have all had to adapt to the way business is being done during COVID times. Here are three ways in which revenue cycles were disrupted over the last year and a half, and some adjustments that can be made to improve profitability.
Automate Appointment Scheduling
Missed appointments equal missed revenue. Front office staff should be made aware of the minimum amount of information needed at scheduling, and these details should be documented. Critical information will include multiple, authorized ways to contact the patient. This enables a robust appointment reminder system to perform and allows your staff to contact no shows. Last week, I scheduled an orthopedic visit for the following week. I have been emailed and texted four times with confirmations, reminders, and paperwork to fill out before the visit. This is robust!
If your practice has adopted telehealth visits during the Public Health Emergency (PHE), consider adding a telehealth visit facilitator. This person can serve multiple functions, including assessment of the telehealth schedule, contacting the patient to make sure they have a strong internet connection required for a telehealth platform, ensuring that it works for 2-way audio capability, obtaining necessary consents, and prompting you when to join the call. Too many telehealth visits are taking longer than in-person due to setup.
Stop Front Desk Dumping
A clean medical claim generally pays in 30 days or less. Is your accounts receivable cycle longer than this? If so, your front desk could be guilty of skipping steps to collect all valid information needed to get the claim paid up front and sending it to the billing department with errors. During the PHE, denials are taking 90-plus days to correct. Why? This can be due to a number of issues. For starters, it typically takes up to one hour hold time to call on a claim. Provider services at the payer are working from home and they are not processing corrected claims. Many claims are processed overseas in countries that are having their own pandemic-related delays. Patients do not answer the phone to update insurance questions. 25% of denials are caused by front-end problems. The good news is this is 100% preventable and can avoid a 90-day delay to correct.
Compile a list of payers that typically require authorizations and whey they require them, then document the process your practice must go through to obtain these authorizations. Keep this information as an electronic file and in a paper binder, so it is easily accessible to the precertification staff. This should be updated on a regular basis.
Make sure a manager verifies the front desk is scanning insurance cards and verifying the plan is active. This is automated in most billing systems. Claims denied for inactive insurance is 100% preventable. Get a copy of the card for every patient, every visit. Verify the insurance is still valid. Now, more than ever, it is important to be sure the patient is actively enrolled in an insurance plan.
Avoid Rejections Due to Coding Errors
Accurate coding is the backbone of successfully paid claims. Coding to the highest level of specificity is what payers look for when they receive claims – along with medical necessity. Procedural and Diagnosis codes that are too vague, or don’t match the procedure or service reported, will result in denials and delayed payments.
Document who is responsible for coding and their exact workflow. If the providers are the coders, they should have a coder available for them to call/text or email any questions for a timely response. Certified coders are recommended, and experience in your practice specialty is a must. I realize this might seem like an added expense. However, a 90-day delay on a rejection that may never get resolved is a crisis for your cash flow.
COVID has changed the way we communicate with the payers. Some carriers no longer answer phone calls. The only way to communicate is to log into the payer site and request a status of the claim. It is taking some billers an average of four attempts per claim to get a resolution to a denied claim. Medical record requests must be loaded on the payer site, if possible. If you mail the requested documents, they almost never get the records the first time. The records are possibly waiting in a mail room for someone to come to the office to scan them. So, follow-up is critical to keep the process moving forward.
Once again, telehealth has its own special set of issues for coding. Each payer has their unique rules regarding billing for telehealth services. Some carriers have changed policies multiple times throughout the pandemic. The best practice is to keep a grid for each payer and any modifications, as required. You should assign someone from your Accounts Receivable team to track any changes monthly and update the grid, as necessary.
Conclusion
You have one chance to get the claim processed. Getting it right the first time matters more than ever before due to pandemic-related resource constraints and consequential delays. Make a mistake and face a 90-day wait. Stacking work on top of already stressed employees is not a sustainable plan for getting claims successfully processed and paid. By defining and streamlining your medical claim processes and taking some of the steps suggested on this article, you better manage the revenue cycle.